This document discusses embolic stroke of undetermined source (ESUS). It defines ESUS as an ischemic stroke that is not lacunar or cardioembolic in origin and with no significant arterial obstruction. The document then lists and describes various potential causes of ESUS including cardiac, infectious, inflammatory, hematological, and other less common etiologies. It also discusses diagnostic criteria and methods for ESUS, clinical aspects of patients with ESUS, and treatment options.

1. ECV DE CAUSA INHABITUAL
Ponente: Dr José Gallardo
R1 Medicina Interna
Tutor: Dr Yimber Matos
Médico Neurólogo
San Cristobal, Febrero 2022
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.

2. ECV DE CAUSA INHABITUAL (ESUS)
Acrónimo en inglés para embolic stroke of unknown source
• No lacunar
• No cardioembólico
• Sin obstruccion aterotrombótica significativa
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.

3. ECV DE CAUSA INHABITUAL (ESUS)
• Enfermedad valvular
• Prolapso mitral
• Endocarditis de Libman-Sacks (ELS)
• Defectos de Septum y foramen oval
• Calcificación de anillo valvular aórtico
Cardiaco
• Fibrilación auricular paroxística
• Placas ulceradas no estenosantes en vasos cervicales
• Valvulopatía mixomatosa con prolapso mitral
No frecuentes
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
ETIOLOGÍA

4. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
• Chagas
• Toxoplasmosis
• Mucormicosis
• Difteria
• Sífilis
• Hiv
• Tbc
• cisticercosis
Infecciones
• Vasculitis
• Hodgkin
• Colitis ulcerativa
• Granuloma linfomatoide
Inflamatorias
• Malformaciones arteriovenosas pulmonares
(MAVP)
• Fistula arteriovenosa pulmonar (ROW)
• Tu pulmonar y mediastínico
Pulmonares

5. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
• Purpura trombocitopenica
• Anticoagulante lúpico
• Anticuerpos anticardiolipina
Inmunológicas
• Anemia drepanocítica
• Policitemia vera
• Trombosis primaria
• Talasemia
Hiperviscosidad
• CID
• Déficit de AT III, Prot C y S, Factor VII
• Sx Paraneoplasicos
• ACO
Trastornos de
coagulación
HEMATOLOGICAS

6. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
• Migraña
• Fármacos
• Drogas
Vasoespasmo
• Síndrome de Marfán
• Síndrome de Ehler-Danlos
• Fabry
Congénitas
• Enfermedad Moya Moya
• Síndrome de Sneddon
• Radiación
Otras causas

7. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
Cáncer y ECV
SINDROME DE TROUSSEAU
• Cáncer de pulmón.
• Cáncer mamario.
• Cáncer de colon.
• Cáncer de riñón.
• Melanoma
• Cistoadenocarcinoma de páncreas

8. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
Criterios diagnósticos para ACV embólico de origen indeterminado (ESUS)
• ACV isquémico (no lacunar) en tomografía o resonancia cerebral
• Ausencia de estenosis arterial superior al 50% de vasos cervicales o intracraneales
• Ausencia de origen cardioembólico de alto riesgo
• Ausencia de otra causa específica de ACV (arteritis, disección, migraña/vasoespasmo

9. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
Métodos diagnósticos para detección de ACV embólico de origen indeterminado (ESUS)a
• Tomografía o resonancia cerebral
• Electrocardiograma de 12 derivaciones
• Telemetría cardiaca con detección automática de ritmo cardiaco por 24h
• Imagen vascular de la arteria involucrada en el territorio del ACV isquémico (ultrasonografía, angiorresonancia,
angiotomografía o angiografía digital)
• Ecocardiograma transtorácico y/o transesofágico

10. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
Aspectos clínicos de los pacientes con ESUS:
• Edad y no sexo como predictor de recurrencias
• Riesgo aumentado 3-8 veces en personas >80 años
• ¿A quien anticoagulamos?

11. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.

12. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
Terapéutica antitrombótica en pacientes con ESUS
• Estudio WARSS
• Evidencia de disminución de disminución de recurrencias en pacientes con
anticoagulación frente a pacientes con antiagregacion

13. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.

14. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
CAUSAS
INFECCIOSA
• TBC
• Herpes zoster
• Cisticercosis
• Sífilis
• Mucormicosis
• Bacteriana
NO
INFECCIOSA
• Takayasu
• Temporal de células gigantes
• Panarteritis nodosa
• LES
• Sjögren
• Wegener

15. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
DISECCIÓN ARTERIAL

16. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
Disección arterial:
 2-22%
 2da mas frecuente en jóvenes
 Mas frecuente en carótida interna (75%)
 Espontáneo o traumático
 Relacionado con displasia fibromuscular

17. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
ENFERMEDAD DE MOYA MOYA

18. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
VASCULOPATÍA INTRACRANEAL OCLUSIVA NO INFLAMATORIA
• Bilateral
• Entre la 1 y 4ta década de la vida
• Sin clínica específica

19. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
SÍNDROME DE SNEDDON

20. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
SÍNDROME DE SNEDDON
 Diagnostico de exclusión
 Relacion > mujeres-Hombres
 Lívedo reticularis
 AIT
 Demencia vascular
 Isquemia periférica en miembros

21. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
MIGRAÑA

22. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
MIGRAÑA
 Historia previa
 Déficit neurológico focal >24hrs
 Presencia de isquemia en imágenes
 Ausencia de otra causa

23. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
Otras causas:
CRACK
ISQUEMIA
COCAÍNA
HEMORRAGIA •ECV((18-33%)
•80-90% Entre
la 3ra y 4ta
década de la
vida

24. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.
RADIOTERAPIA
 EXTRACRANEAL: Ateroesclerosis acelerada
 INTRACRANEAL: Lesión de pequeños vasos

25. ECV DE CAUSA INHABITUAL (ESUS)
Classification of subtype of acute ischemic stroke, Definitions
for use in a multicenter clinical trial. TOAST. Trial of Org 10172
in Acute Stroke Treatment.